Patient Drop-Off Exam Information

Patient Drop-Off Exam Information
Document generation date*

MonthDayYear
Client*

First NameLast Name
Email
PATIENT
Name*
MEDICAL HISTORY
When did you first notice your pet's problem?*
Last seen
Current on Rabies vaccine

YesNo
Current on other vaccines

YesNo
Drug consultation

YesNo
Would You like us to update any past due vaccines during your pet's visit?
Current Rabies Vaccine is mandatory, the vaccine will be given if no proof of a current vaccine is provided.
Yes No*
Lifestyle

IndoorOutdoorBoth
Attitude

Bright/Alert/ResponsiveQuiet/DepressedOther
Appetite

NormalIncreasedDecreased
Drinking

NormalIncreasedDecreased
Diet
Treats/Supplements
Dental Hygiene

Dental ChewsBrushing TeethNone
Defecation

NormalAbnormal
If Abnormal, explain
Urination

NormalAbnormal
If Abnormal, explain
Vomiting

YesNo
Coughing

YesNo
Sneezing

YesNo
History of Seizures

YesNo
Access to poisons, pesticides, or other harmful substances

YesNo
If yes, please list
Allergies
Limping/Lameness
Masses
Heartworm Prevention

OralInjectableNone
Flea/Tick Prevention

OralInjectableNone
Microchip

YesNo
Would you like a nail trim today?

YesNo
Behavioral Issues
Other Concerns
CONSENT FOR TREATMENT
Do we have permission to sedate your animal, if necessary?
To diagnose and treat many problems, radiographs, blood tests, and other diagnostic procedures may be needed. Please read the statement below and inform us of any questions or concerns that you may have regarding today's procedure(s). In the event of a lifethreatening condition, we will stabilize your pet and call you as soon as possible. Please make certain you leave a phone number where you can be reached. Payment for services rendered is due at time of discharge.

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.

I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.

I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication.

The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.
Please select one of the following options

I wish to be contacted with a treatment plan after an examination is completed and before any additional treatment not previously discussed is performed. I understand that if I cannot be reached in order to discuss additional treatment, any further procedures may need to be rescheduled for a future date based on time constraints.I pre-approve treatment as the veterinarian deems necessary, up to $(please mention in below box). I understand that the veterinary staff will contact me for further consent if the recommended treatment will go over this pre-approved dollar amount.
CPR/DNR
In the event that your pet should experience cardiac or respiratory arrest while boarding, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet's status?

By consenting to this service, you are also acknowledging that certain charges will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.
I agree to CPR being performed in case of arrest and agree to any financial obligations as a result of CPR being performed regardless of outcome.I elect a “Do Not Resuscitate” status in case of arrest.
Phone number(s) where you can be reached today
If you cannot be reached at the phone number provided above, we will not proceed with the procedure or treatment. This can cause delays in pick-up times, and our ability to treat your pet. You will be still be charged for any services performed.
OWNER RELEASE AND CONSENT

MVVH Orland, Inc., doing business as Mid-Valley Veterinary Hospital, will use all reasonable precautions against injury, escape, or death of your pet. I understand that anesthesia and surgery always involve some risk to your pet and agree to hold Mid-Valley Veterinary Hospital harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the below-listed phone number, Mid-Valley Veterinary Hospital is directed to make the decision(s) it deems best for my pet. I have read the foregoing, understand what it says, and hereby accept and agree to these terms.
Date

MonthDayYear
Phone number(s) where you can be reached today
Signature

Clear
Should be Empty:

Patient Drop-Off Exam Information

PATIENT

MEDICAL HISTORY

CONSENT FOR TREATMENT

CPR/DNR

OWNER RELEASE AND CONSENT